Depo Provera, an injectable, is the most widely used and easy to administer contraceptive in public facilities across South Africa, and the ongoing stockouts leave many women who depend on it at a loss, without alternatives.
This is the warning from Indira Govender of Rural Doctors Association of Southern Africa, and founding member of the Stop Stockouts Project (SSP).
Govender was speaking at The Rural Health Advocacy Project's release of a new report Health System Strengthening Post-Covid-19 on 12 December in Sandton. The report drives home the degree to which medicine and vaccine stocks in rural primary health care facilities have been compromised due to the supply-chain disruptions caused by the Covid-19 lockdowns.
Presented on Universal Health Coverage Day, the report highlights the impact the Covid-19 pandemic has had on the delivery of essential health services, and showed that there were stockouts of many vital medications, particularly contraceptives such as intrauterine devices, implants, the contraceptive pill, injectables and condoms in the majority of South Africa's provinces.
A 2022 independent study by Ritshidze project, a community clinic monitoring organisation, indicates that stock-outs of contraceptives represented 40% of all medicine stock-outs reported.
Ritshidze's information on depleted birth control stocks was sourced from 400 primary health care facilities in South Africa, where the demographic of people using these facilities are majority women of child-bearing age, with 63% of them living with HIV.
"Between April and June this year, the study showed, that - while there have been improvements to the access to contraceptives since the lockdowns, (83% of the 14,815 women interviewed across seven provinces said they had never left a facility without the medicine they wanted to get,) - 7% said they walked out of a clinic in 2022 without their contraception as it was not in stock," Govender explained.
"When asked what type of contraceptive they were unable to receive, 20% said oral contraception; 27% said the injectable contraceptive.
"When facility staff were asked if they had any knowledge of stockouts at the facility, 54% said no, and 17% said there was a shortage of contraceptives. When they were asked what type of contraceptive had experienced stockouts, 81% said the injectable contraceptive, Depo Provera."
"According to a 2003 Demographic and Health Survey, as well as the 2012 South African National HIV prevalence incidence Behavior Survey, the most popular contraceptive among South African women is the Depo injection.
"When women in the Ritshidze Project survey were asked whether they received their contraception of choice, 96% of those interviewed said 'yes', which is good, excellent. But then 4.4% said 'no'.
"So we looked at those 4.4%. And we asked them: 'What were your reasons for not getting the contraception?' The top three reasons are: 'They told me there was a stockholder shortage'; 'They told me I had to come back; 'They told me my first choice was not available'."
These really speak to the supply issue.
"Then we've also got very problematic reasons for people not getting their contraception. They're being told they're young, or that they can't get it because they're a sex worker, or because they are a person who uses drugs.
"These may be small number of women reporting this, but these are people's experiences in our services."
But even before Covid-19 hit, the supply chain of contraceptives had already been under strain, says Govender. In 2018, SSP raised the alarm bells, but it had been passively monitoring access to medicines and medicine availability in public health clinics and hospitals from as far back as 2013, and periodically led surveys on antiretrovirals, TB medicine and vaccines.
"Then around 2019, just before the pandemic, we started getting reports that clinics and public health services - mainly in rural provinces - were in short supply of contraceptives, or they were just completely out of stock," Govender says.
"The feedback at the time was considered anecdotal evidence, and so it was easy for the Department of Health to dismiss it when the news was shared.
"There wasn't much improvement on the situation.
"Then SSP aligned its research questions with a survey being done by the Ritshidze Project - which monitors the quality of HIV services in 400 clinics across SA."
And the data on the numbers of women who aren't able to receive their contraception of choice speaks for itself.
"Some people may argue that women can always be offered an alternative contraceptive, but these things essentially infringe on their bodily autonomy and psychosocial well-being," Govender says.
"Condom use is not an easy thing to negotiate. Some people don't disclose what type of contraception they're using with their partners, and so having to negotiate condom use becomes a challenge.
"There are socio-economic stresses associated with using alternative contraceptives, where women may have to find another source of contraception that is not free, or make multiple trips to a health facility because they're told to come back on another day - or they're given a different type of contraception that doesn't last two months - they only get it for a month - and they have to pay money to go back to the clinic to get it. Or they go to another clinic, and it's not there.
"All these costs need to be factored in."
"In the South African context where misogyny and gender-based violence are widespread, we cannot afford a deprioritisation of women's sexual reproductive health issues," Govender says.
To avert further erosion of the right to sexual reproductive health, the SSP is calling on the National Department of Health to review the supply-chain management and distribution procedures of contraceptives and produce a comprehensive remediation plan that prioritises contracts with reliable suppliers who can ensure an uninterrupted supply of contraceptives to facilities.
"We recommend that government urgently create a plan to address contraceptive stockouts in primary healthcare facilities, including shortening the time resolution of stockouts, where they occur, provide guidelines for how primary health care facilities should manage stockouts should they occur, monitor the implementation of the National Integrated Sexual and Reproductive Health Rights policy, including promoting long-term removable contraception, such as IUDs and implants (with the implant we can ensure that stocks are met) and then ensure that women and girls are able to access their preferred contraceptive.
"In addition to reviewing and improving the current systems of supply chain management and distribution for contraceptives, SSP is calling for the development of a standard referral guideline to be circulated to health facilities, that describes how clinical staff must handle stockouts and appropriately advise women who are unable to access the contraceptive of their choice at the initial point of service.
“The impact of a lack of access to contraceptives places women at increased risk of unwanted pregnancy, economic stress and compromises their psychological well-being. All of which undermines reproductive and contraceptive health rights."
